The role of Special Interest Groups (SIGs) within IUGA is to facilitate the sharing of ideas and resources among members with a common urogynecological interest, and to undertake projects related to that area of interest in order to advance the IUGA mission. Participation in a SIG provides members with opportunities to grow existing professional relationships and establish new professional relationships within the individual SIG community.

Members may belong to multiple SIGs. The Board of Directors approves the creation of all SIGs. A group of 10 active IUGA members or the Board of Directors may form a SIG.

There are currently 7 established SIGs:

• Basic Science
• Cosmetic Urogynecology
• Minimally Invasive Endoscopic Surgery
• Neuro-urogynecology and Urogenital Pain
• Obstetric Pelvic Floor & Anal Sphincter Injuries
• Pelvic Floor Imaging
• Pelvic Floor Rehabilitation

Background

As urogynecologists, we are specialists who address women’s functional and anatomical changes to the pelvic floor as a result of childbirth, aging, and other factors. Many of these women – our patients who we see daily – also complain of changes in sexual function and genital aesthetic appearance. It is our duty as pelvic floor specialists to understand these concerns and either address them or refer them to the best qualified surgeon.

Cosmetic Gynecology has become one of the fastest growing subspecialties of elective surgery for women and includes specialists in gynecology, urogynecology, urology, and plastic surgery. This area of special interest includes both cosmetic procedures to enhance the aesthetic appearance of the vulvo/vaginal region, as well as functional vaginal repairs to enhance or help restore sexual function following the changes that may occur following childbirth and/or aging.   

Among the first procedures covered by this subspecialty – and the most controversial and discussed – is colloquially named Vaginal Rejuvenation (VR), which is performed to treat the vaginal laxity syndrome (VLS). For many years it has been shown scientifically that prolapse affects sexual function, and when repaired, sexual function improves. Vaginal rejuvenation surgery (vaginal tightening for sexual function) is the repair of VLS that may or may not involve symptomatic prolapse. In the early years of these procedures there was very little scientific evidence to support this type of surgery, however in the recent years scientific studies supporting vaginal rejuvenation are surfacing and being presented at scientific meetings throughout the world. Scientific articles as well as book chapters in very reputable female urology textbooks (example: Cardoza and Staskin) are becoming more prevalent as the procedure is becoming more mainstream. Certainly, however, it is vitally important for more high level scientific studies to be completed to validate these procedures in women.

Female genital cosmetic surgery also includes aesthetic procedures to improve the cosmetic appearance of the external vulvar/vaginal region. Procedures include labiaplasty or labia minora reduction with or without excess prepuce reduction, labia majora reduction or augmentation, vaginal introital repairs for cosmetic issues as well as reduction of lipodystrophy in the mons pubis region. Labiaplasty procedures have been reported to be the largest growing trend of plastic or cosmetic surgery procedures for women in the US and throughout the world. This may be secondary to the increased public awareness created by the media or popular TV shows, or it may be secondary to the fact that in the past women’s feelings about the appearance of their genitalia have been ignored. It has been scientifically shown that the appearance of a woman’s genitalia affects her self-confidence and sexuality. Women now have been empowered with the choice of options to change the external appearance of their vulvovaginal region if they are unhappy with the cosmetic appearance. Studies have also recently shown that this is a trend driven by women themselves, and not their sexual partners. However, with this trend there have been many different procedures described with very little scientific validation and therefore there is a danger that surgeons with very little experience with vulvar or vaginal surgery (inside or outside the field of gynecology) are doing these procedures incorrectly and causing injury or damage to women.    

Recently, new technology has been introduced in the field offering non-surgical/office based procedures to treat female sexual dysfunction (VLS), vaginal health and vulvo/vaginal cosmetic issues for women. This technology includes non-fractional lasers as well as radiofrequency treatments. Scientific studies are currently evaluating this technology for these uses as well as treatment for mild urinary incontinence, urgency/frequency issues as well as vaginal dryness.   

What do doctors who perform these procedures have in common? 

The leaders of these procedures and technology worldwide, with few exceptions, come from the area of urogynecology. This is not surprising considering that of the four subspecialties within Obstetrics and Gynecology (perinatology, reproductive endocrinology, oncology, urogynecology) only urogynecology deals with the management of pelvic floor disorders. Thus, this subspecialty is best suited to address the aesthetic, functional, and sexual concerns of women and should be taking the lead in this newly developing field. No other subspecialty has the expertise that our specialty has in vaginal reconstructive surgery, and we should therefore not let other specialties take the lead on these procedures or the scientific validation of these procedures.  

We may categorically say that there are no less than 20 courses or symposiums on Cosmetic Gynecology running every year worldwide. If we add countless lectures, conferences and training courses, we are facing a new area of gynecology that is growing exponentially and is impossible to stop. We urogynecologists have noted with concern that many of these procedures, whether performed in isolation or in association with other conventional surgeries such as hysterectomies, urinary incontinence correction and prolapse correction, are being performed by other health professionals who, in our opinion, are not the most suitable.

Due to the aforementioned facts, a group of IUGA members with proven experience and interest in aesthetic/cosmetic vulvo-vaginal surgery have created the Cosmetic Gynecology Special Interest Group.

Aims and Objectives of the Group

• Define, spread and explain within IUGA the different surgical and non-surgical procedures and their different applications, including the adequate selection of patients.
• Properly establish that in the vast majority of cases, due to associated pathologies,

urogynecologists are the most suitable professionals to perform such procedures, including non-surgical procedures that also require a previous evaluation by a specialist who will give the patient the best treatment choice to his/her reason for consultation. 

• Promote the presentation of scientific publications on cosmetic gynecology within IUGA.
• Help promote the scientific validation of cosmetic and functional aesthetic vaginal procedures (both surgical and non-surgical) both within IUGA as well as outside the organization.
• Promote IUGA as a leader in the field of Vaginal/Vulvar Reconstructive and Aesthetic procedures.
• Promote women’s sexual health and sexual function through studies, courses, and grants to IUGA.

Follow the Cosmetic Gynecology SIG on the IUGA E- Discussion Forum. Click here or sign up through your IUGA Member Page by clicking the Special Interest Groups box.

SIG Leadership

Chair: Keng (KJ) Ng (United Kingdom)

Background

The pelvic floor is a highly complex structure made up of skeletal and striated muscle, support and suspensory ligaments, fascial coverings, and an intricate neural network. Its dual role is to provide support for the pelvic viscera (bladder, bowel and uterus) and maintain functional integrity of these organs. In order to maintain good pelvic floor function, this elaborate system must work in a highly integrated manner. When this system is damaged, either directly or as a consequence of an underlying neurological condition, pelvic floor failure ensues along with organ dysfunction. The etiology is inevitably multi-factorial, and seldom as a consequence of a single etiological factor. It can affect one or all three compartments of the pelvic floor, often resulting in prolapse and functional disturbance of the bladder (urinary incontinence and voiding dysfunction), rectum (fecal incontinence), vagina and/or uterus (sexual dysfunction). This compartmentalization of the pelvic floor has resulted in the partitioning of patients into urology, gynecology, colo-rectal surgery, or neurology, depending on the patient’s presenting symptoms. In complete pelvic floor failure, all three compartments are inevitably damaged resulting in apical prolapse, with associated organ dysfunction. It is clear that in this state, the patient needs the clinical input of at least two of the three pelvic floor clinical specialties. While the primary clinical aim is to correct the anatomy, it must also be to preserve or restore pelvic floor function. These patients need careful clinical assessment, appropriate investigations, and counselling before embarking on a well-defined management pathway. The latter includes behavioral and lifestyle changes, conservative treatments, pharmacotherapy, minimally invasive surgery, and radical specialized surgery. It is not surprising that in this complex group of patients, a multi-disciplinary approach is not only necessary, but critical, if good clinical care and governance is to be ensured.

Neural Control of the Uro-genital System

Voluntary control over the uro-genital system is critical to our social existence. Since its peripheral innervation derives from the most distal segments of the spinal cord, integrity of the long tracts of the central nervous system for physiological function is immediately apparent. In a survey of patients referred with bladder symptoms, spinal cord involvement of various pathologies was found to be the most common cause of bladder symptoms. Because of the commonality of innervation shared by the bladder and genital organs, it might be expected that abnormalities of these two systems inevitably occur together. This, however, is not the case because although the organs share the same root innervation and have common peripheral nerves within the pelvis, each is controlled by its own unique set of central nervous system reflexes. The bladder performs only two functions - storage and voiding of urine- and the modern view of the control of these two mutually exclusive activities is that whereas storage is organized within the spinal cord, micturition results from activation by suprapontine influences of a center in the dorsal tegmentum of the pons, the pontine micturition center (PMC). In neurological disease, this delicate interaction can be severely disrupted, and manifests as a disorder of voiding or storage depending on the condition such as multiple sclerosis, Parkinson's disease, multiple system atrophy and others. But commonly, it is direct injury to pelvic nerves that can give rise to quite marked bladder and pelvic floor dysfunction. The peripheral innervation of the pelvic organs can be damaged by extirpative pelvic surgery such as resection of rectal carcinoma, radical prostatectomy, or radical hysterectomy. The dissection necessary for rectal cancer is likely to damage the parasympathetic innervation to the bladder and genitalia, as the pelvic nerves take a medio-lateral course through the pelvis on either side of the rectum and the apex of the prostate. The nerves may either be removed together with the fascia which covers the lower rectum or may be damaged by a traction injury as the rectum is mobilized prior to excision. Urinary incontinence following radical hysterectomy which includes the upper part of the vagina, is probably also due to damage to the parasympathetic innervation of the detrusor and in the case of a radical prostatectomy, there may be additional direct damage to the innervation of the striated urethral sphincter. The focus in the literature tends to focus on the effects of neurological disease on the bladder, but other pelvic floor effects should not be ignored, such as pelvic organ prolapse, pain syndromes, and sexual dysfunction.

Aims and Objectives

This SIG will focus on improving obstetricians and gynecologists understanding of the neurological basis of pelvic floor dysfunction and the associated clinical disorders, which hitherto have not been fully characterized in the literature.

Follow the Neuro-urogynecology & Urogenital Pain SIG on the IUGA E- Discussion Forum. Click here or sign up through your IUGA Member Page by clicking the Special Interest Groups box.

SIG Leadership

Chair: Abdul Sultan (UK)

Background

Perineal and vaginal injuries are common during childbirth, and up to 80% of primiparous women need suturing after a vaginal delivery. First and second degree perineal injuries rarely cause long-term health problems, but third and fourth degree injuries, which include anal sphincter muscle trauma, are associated with increased risk for anal incontinence (AI), pain, discomfort and sexual dysfunction. Reported incidence of obstetric anal sphincter injury (OASI) varies from 1 to 6% in different delivery units and countries. Main risk factors for OASI are large infant birth weight and instrumental delivery, but OASI occurs even in otherwise uncomplicated deliveries.

Injuries in deep muscles such as levator ani are also common during vaginal delivery with reported incidences from 13 to 30% among primiparous women. Risk factors for levator ani muscle trauma are similar to OASI risk factors – large fetal head circumference and instrumental delivery, especially forceps. OASI is associated with levator ani muscle avulsion, also indicating uniform risk profile for these complications. Levator ani muscle injury is associated with pelvic organ prolapse, commonly needing surgical repair later in life. Similarly, risk for urinary incontinence increases with delivery of a large infant and with increasing parity. Non-obstetrical factors such as aging, menopause, and being overweight are also associated with the mentioned pelvic floor disorders, but previous injuries during childbirth may increase the risk of complaints following aging.

Existing studies indicate that pelvic floor injuries and also complaints and complications associated with these injuries can be reduced. Choosing clinical routines that reduce pelvic floor trauma (manual perineal protection, correct use of episiotomy, avoiding forceps delivery, optimal birth positions) will reduce the OASI risk during childbirth. Optimal management of the perineum immediately after delivery (diagnostics and repair) reduce the occurrence of anal and urinary incontinence. Pelvic floor muscle training before and after childbirth may also reduce the risk of incontinence later in life. There is still much to do to improve women’s health during and after vaginal delivery, and this Special Interest Group aims at adding knowledge and education for birth attendants around the world.

Aims and Objectives

The main aim for this Special Interest Group is to study clinical routines optimal for reducing pelvic floor trauma during delivery and focusing mainly on obstetric anal sphincter trauma. Additionally, we aim to:

• Add knowledge on managing pelvic floor trauma to reduce complications and complaints for the woman.
• Add knowledge on health effects of obstetric pelvic floor trauma.
• Develop educational tools for easy and economical knowledge transfer for prevention of pelvic floor trauma.
• Promote safe vaginal birth globally to reduce the need for unnecessary caesarean deliveries.

Existing Knowledge and Knowledge Gaps

OASI
Maternal, fetal and obstetrical risk factors for OASI have been widely studied with focus on non-modifiable patient related factors such as maternal age, ethnicity, fetal weight and head size, but many women suffering from OASI have no risk factors, as most OASI occur during spontaneous delivery with a normal size infant. Therefore, attempts to create risk-scoring systems to predict OASI on individual level have not been successful. OASI is an infrequent event and often occurs without predicting factors, when a normal childbirth is expected.

Many pelvic floor disorders are associated with vaginal delivery, especially “difficult delivery” with a large infant and/or instrumental delivery. Risk factors unrelated to the delivering woman or the infant size, such as the accoucheurs’ management of the second stage of delivery, have been less investigated. Some of the complications might be avoided or at least the risk for the complication might be reduced with choices made during the delivery. Observational studies reveal that clinical routines and choices during delivery may decrease the risk of OASI:

• Routine use of manual perineal protection
• Correct use of episiotomy when clinically indicated
• Correct cutting of episiotomy with a 60° angle at crowning
• Avoiding median/midline episiotomy
• Choosing vacuum extraction instead of forceps
• Birth position
• Pushing technique

Levator Ani Muscle
Risk factors with OASI are coinciding, but whether the mentioned procedures protect women from levator ani muscle injuries has not been studied. Slower expulsion of fetal head may reduce the risk of levator ani injuries also.

Quality of Life
Methods to assess quality of life among women in fertile age are scarce. Conclusions in previous studies on pelvic floor disorders and quality of life are conflicting. Women with anal incontinence may not score reduced QoL. Whether the measuring tools are not suitable for women in fertile age or these women adapt to a life with anal incontinence is unknown.

Pelvic Floor Muscle Training
The conclusions of existing research of the role of pelvic floor muscle training for treatment and prevention of pelvic floor dysfunction are conflicting, and more research is needed. Training during pregnancy and after delivery needs to be explored.

Group Research

• There is still need for more research on OASIS, anal incontinence, pelvic organ prolapse, urinary incontinence and quality of life.
• The combination of obstetrical and non-obstetrical risk factors for pelvic floor injuries need to be assessed.
• Pelvic floor injuries, delivery and protective clinical routines in different countries and delivery units:
  • Quality of episiotomy with correct angle
  • Frequency of episiotomy use
  • Use of manual perineal protection
  • Postpartum follow-up
  • Patient information/support

Quality of Life Measurement Tool

• To assess associations between pelvic floor dysfunction and quality of life (QoL) among women in fertile age. The existing questionnaires for QoL may fail to identify effect on QoL among women in fertile age.

Networking and Collaboration

• Collaboration (interdisciplinary and multi-professional); health care providers
• Collaboration with midwifery and obstetric colleges and researchers.
• Health care authorities and policy makers globally

Education and Training

• Diagnostics and repair
• Prevention of delivery/pelvic floor injuries
• Management of incontinence, including all healthcare professionals
• Education should also be offered in developing countries, where problems with incontinence are notable.
• Development and implementation of training programs to reduce pelvic floor injuries during vaginal delivery

Patient Information

• How to seek help in health care
• How to cope with living with incontinence and pelvic floor dysfunction
• How to give birth in next pregnancy after pelvic floor injury
• Pelvic floor muscle training

Dissemination

• Publications in scientific journals
• Popularized communication such as social media
• Patient organizations

Implementation

The group aims to meet during annual IUGA meetings with additional contact via Skype-meetings and email communication.

The group is multi-professional and international, giving us an opportunity to conduct multi-center clinical studies with large numbers of patients, working alongside IUGA’s Research & Development Committee). We can communicate with clinicians directly ensuring close cooperation with practicing obstetricians, midwives, and urogynaecologists. Knowledge achieved from research may easily and rapidly be implemented without delay through agreed training programs, e.g. Care Bundle in the UK and the national interventional program for reducing the risk of OASIS in Norwegian delivery units. Feedback from clinicians from different cultures can be used to develop studies and education.

Follow the Obstetric Pelvic floor & Anal Sphincter Injuries SIG on the IUGA E- Discussion Forum. Click here or sign up through your IUGA Member Page by clicking the Special Interest Groups box.

SIG Leadership

Chair: Kamil Svabik (Czech Republic)

Aims and Objectives

• To create a space where members with an interest in imaging can interact
• To exchange tips and tricks, technical information and new ideas
• To discuss clinical indications and research applications of imaging techniques
• To provide enhanced opportunities for research collaboration
• To advise IUGA on educational matters involving imaging, including website and meeting content
• To assist IUGA in efforts to standardize performance and evaluation of imaging examinations
• To advance imaging in urogynecological practice.

Documents

Pelvic Floor Ultrasound: Basic Settings and Procedures (ENGLISH)

Pelvic Floor Ultrasound: Basic Settings and Procedures (CHINESE)

Pelvic Floor Ultrasound: Basic Settings and Procedures (FRENCH)

Pelvic Floor Ultrasound: Basic Settings and Procedures (PORTUGUESE)

Pelvic Floor Ultrasound: Basic Settings and Procedures (SPANISH)

Pelvic Floor Ultrasound: Basic Settings and Procedures (GERMAN)

This document has been produced by the Pelvic Floor Imaging SIG to provide instruction for the acquisition of ultrasound images and 3D/4D data sets obtained by translabial imaging, which is currently the most widely used method for pelvic floor imaging. It is recognized that some practitioners use transvaginal and endo-anal techniques, to which this text does not apply.

Follow the Pelvic Floor Imaging SIG on the IUGA E- Discussion Forum. Click here or sign up through your IUGA Member Page by clicking the Special Interest Groups box.

SIG Leadership

Chair: Cristiane Carboni (Brazil)

 SIG Goals

• Increase awareness and a positive attitude to the significance of pelvic floor physiotherapy as a method of non-surgical pelvic floor rehabilitation or conservative treatment in female pelvic floor disorders;
• Enhance the scientific knowledge on pelvic floor physiotherapy among IUGA members;
• Increase the use of pelvic floor physiotherapy among IUGA members;
• Increase the number of IUGA physiotherapy members.

Follow the Pelvic Floor Rehabilitation SIG on the IUGA E- Discussion Forum. Click here or sign up through your IUGA Member Page by clicking the Special Interest Groups box.